[104-10222-10040.pdf — page 136]
# STATEMENT OF PRIOR FEDERAL CIVILIAN AND MILITARY SERVICE AND DETERMINATION OF COMPETITIVE STATUSIMPORTANT: The information on this form will be used (1) in determining creditable service for leave purposes and retention credits for reduction in force, and (2) in recording agency determination of competitive status. The employee should complete Part I and the Personnel Office should complete Parts II through V.PART I.—EMPLOYEE'S STATEMENT1. NAME (Last, first, middle initial)Shaw, Robert T.2. DATE OF BIRTH6/18/253. LIST THE FOLLOWING INFORMATION CONCERNING ALL FEDERAL AND DISTRICT OF COLUMBIA SERVICE YOU HAVE HAD PRIOR TO YOUR PRESENT APPOINTMENT (Do not include military service)PART II—THIS COLUMN IS FOR PERSONNEL OFFICE USE9. RETENTION GROUP10. A. COC STATUS YES    B. TYPE OF PRESENT APPOINTMENT| NAME AND LOCATION OF AGENCY |     FROM-      |      TO-       | TYPE OF APPOINTMENT IF ANOWN |  11. SERVICE   |     |     || --------------------------- | :------------: | :------------: | :--------------------------: | :------------: | :-: | --- ||                             | YEAR MONTH DAY | YEAR MONTH DAY |                              | YEAR MONTH DAY |     |     || FOREIGN SERVICE             |   49 OCT 19    |    52 FEB 6    |                              |       2        |  3  | 18  || FOREIGN SERVICE             |   52 MAY 28    |   54 JULY 30   |                              |       2        |  2  | 1   || DEPT. OF DEFENSE, WASH.     |   54 JUL 31    |    56 APR 6    |                              |       1        |  8  | 6   |NO SICK OR ANNUAL LEAVE TO BE PICKED UP.4. LIST PERIODS OF ACTIVE SERVICE IN ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES. IF YOU HAD NO ACTIVE MILITARY SERVICE, WRITE "NONE".| BRANCH    |     FROM-      |      TO-       | DISCHARGE (Hon. or dishon ?) || --------- | :------------: | :------------: | :--------------------------: ||           | YEAR MONTH DAY | YEAR MONTH DAY |                              || U.S. ARMY |   43 SEP 11    |    45 MAR 8    |             HON.             |12. TOTAL SERVICE,5. DURING PERIODS OF EMPLOYMENT SHOWN IN ITEM 3, DID YOU HAVE A TOTAL OF MORE THAN 6 MONTHS ABSENCE WITHOUT PAY, INCLUDING PERIODS OF MERCHANT MARINE SERVICE, DURING ANY ONE CALENDAR YEAR?YES ☑ NOIF ANSWER IS "YES," LIST FOLLOWING INFORMATION.| TYPE IF KNOWN (LWOP, Furl, Susp. AWOL, Mor Mar) |     FROM-      |      TO-       |     TOTAL     || ----------------------------------------------- | :------------: | :------------: | :-----------: ||                                                 | YEAR MONTH DAY | YEAR MONTH DAY | YEARS HOT MTS |13. NONCREDITABLE SERVICE (Leave purposes only):14. NONCREDITABLE SERVICE (RIF purposes only):6. DURING THE FEDERAL SERVICE LISTED IN ITEM 3, DID YOU ACQUIRE A PERMANENT COMPETITIVE CIVIL SERVICE STATUS?YES ☐ NO(If answer is "Yes," in what agency were you employed at the time status was acquired?)7. ARE YOUA. THE WIFE OF A DISABLED VETERAN? YES ☐ NOB. THE MOTHER OF A DECEASED OR DISABLED VETERAN? YES ☐ NOC. THE UNREMARRIED WIDOW OF A VETERAN? YES ☐ NO8. TO BE EXECUTED BEFORE A NOTARY PUBLIC OR OTHER PERSONS AUTHORIZED TO ADMINISTER OATHS.I swear (or affirm) that the above statements are true to the best of my knowledge and belief.EOD May 17, 1956(DATE)Subscribed and sworn to before me on this 17th day of May 19 55 at Washington, D.C.(MONTH) (CITY) (STATE)SEALNOTE: If oath is taken before a Notary Public, the date of expiration of his Commission should be shown.INSTRUCTIONS: File this form on the permanent side of the employee's official personnel folder immediately before or after the personnel action involved.(OVER)